Hemiarthroplasty versus nonoperative treatment of displaced 4-part proximal humeral fractures in elderly patients: a randomized controlled trial

Olerud, Per; Ahrengart, Leif; Ponzer, Sari; Saving, Jenny; Tidermark, Jan

doi:10.1016/j.jse.2011.04.016

Cited by 242 publications

(216 citation statements)

References 42 publications

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“…The low-to-moderate pain level found in this study corresponds with results from previous studies [30,[38][39][40]. Pain levels favored operative treatment with a difference of 0.8 on the VAS, which is very similar to the 1.0 points lower score after hemiarthroplasty reported by Olerud et al [30].…”

Section: Discussionsupporting

confidence: 90%

“…This finding supports the claim that this type of injury influences physical functioning in the long term. The results in functional outcome of this study correspond with functional outcome measured in several previous studies [12,30]. Some studies do report better functional outcome, probably due to the inclusion of patients with 2-part fractures and patients of 18 years and older, resulting in a lower mean age of the study cohort compared to this study [35][36][37].…”

Section: Discussionsupporting

confidence: 86%

“…Pain levels favored operative treatment with a difference of 0.8 on the VAS, which is very similar to the 1.0 points lower score after hemiarthroplasty reported by Olerud et al [30]. Lack of power could be the reason that both studies failed to show statistical significance.…”

Section: Discussionsupporting

confidence: 81%

“…Many previous studies also included younger patients, inclusion starting from 18 years of age, and 2-part fractures [6,29]. Some studies chose to include only 3-part or only 4-part fractures but not both [12,30]. This should not be overlooked when comparing results.…”

Section: Discussionmentioning

confidence: 99%

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Traumatic diaphragmatic rupture in pediatric age: review of the literature

Marzona

Parri

Nocerino

et al. 2016

Eur J Trauma Emerg Surg

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Purpose Despite a rising incidence in proximal humeral fractures, there is still no evidence for the best treatment option, especially for elderly patients. The aim of this retrospective cohort study was to evaluate health-related quality of life (HRQoL), functional outcome, pain and social participation in elderly patients, after operative and nonoperative treatment of displaced 3-and 4-part proximal humeral fractures. Methods 150 patients aged ≥ 65, treated for a displaced 3-or 4-part proximal humeral fracture between 2004 and 2014, were invited to participate. Eventually 91 patients (61%) participated, of which 32 non-operatively treated patients were matched to 32 of the 59 operatively treated patients by propensity score matching. The EQ-5D, DASH, VAS for pain and WHODAS 2.0 Participation in Society domain were administered. Complications and reinterventions were registered. Results No significant difference was found between the two treatment groups in HRQoL (p = 0.43), function (p = 0.78) and pain (p = 0.19). A trend toward better social participation in the operative group (p = 0.09) was found. More complications and reinterventions occurred in the operative group than the nonoperative group, with 9 versus 5 complications (p = 0.37) and 8 versus 2 reinterventions (p = 0.08). Conclusions In this study, we found no evidence of a difference in HRQoL, functional outcome or pain 1-10 years after operative or nonoperative treatment in patients of 65 and older with a displaced 3-or 4-part humeral fracture. Operatively treated patients showed a trend toward better social participation but also higher reintervention rates.

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Section: Discussionsupporting

confidence: 90%

Section: Discussionsupporting

confidence: 86%

Section: Discussionsupporting

confidence: 81%

Section: Discussionmentioning

confidence: 99%

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Traumatic diaphragmatic rupture in pediatric age: review of the literature

Marzona

Parri

Nocerino

et al. 2016

Eur J Trauma Emerg Surg

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“…The update published in 2012 (search date January 2012) included six trials (270 participants) comparing surgery with non-surgical treatment but noted also six ongoing trials that aim to recruit 1052 patients in all. 30 All three of the more recent trials [31][32][33] recorded validated patient-reported outcome measures of upper limb function. Such measures, which include the Disabilities of the Arm, Shoulder and Hand questionnaire 34 and the Oxford Shoulder Score (OSS), 35 were unavailable previously.…”

Section: Evidence Underpinning Practicementioning

confidence: 99%

The ProFHER (PROximal Fracture of the Humerus: Evaluation by Randomisation) trial – a pragmatic multicentre randomised controlled trial evaluating the clinical effectiveness and cost-effectiveness of surgical compared with non-surgical treatment for proximal fracture of the humerus in adults

Handoll

Brealey

Rangan

et al. 2015

Health Technology Assessment

105

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BackgroundProximal humeral fractures account for 5–6% of all fractures in adults. There is considerable variation in whether or not surgery is used in the management of displaced fractures involving the surgical neck.ObjectiveTo evaluate the clinical effectiveness and cost-effectiveness of surgical compared with non-surgical treatment of the majority of displaced fractures of the proximal humerus involving the surgical neck in adults.DesignA pragmatic parallel-group multicentre randomised controlled trial with an economic evaluation. Follow-up was for 2 years.SettingRecruitment was undertaken in the orthopaedic departments of 33 acute NHS hospitals in the UK. Patient care pathways included outpatient and community-based rehabilitation.ParticipantsAdults (aged ≥ 16 years) presenting within 3 weeks of their injury with a displaced fracture of the proximal humerus involving the surgical neck.InterventionsThe choice of surgical intervention was left to the treating surgeons, who used techniques with which they were experienced. Non-surgical treatment was initial sling immobilisation followed by active rehabilitation. Provision of rehabilitation was comparable in both groups.Main outcome measuresThe primary outcome was the Oxford Shoulder Score (OSS) assessed at 6, 12 and 24 months. Secondary outcomes were the 12-item Short Form health survey, surgical and other shoulder fracture-related complications, secondary surgery to the shoulder or increased/new shoulder-related therapy, medical complications during inpatient stay and mortality. European Quality of Life-5 Dimensions data and treatment costs were also collected.ResultsThe mean age of the 250 trial participants was 66 years and 192 (77%) were female. Independent assessment using the Neer classification identified 18 one-part fractures, 128 two-part fractures and 104 three- or four-part fractures. OSS data were available for 215 participants at 2 years. We found no statistically or clinically significant differences in OSS scores between the two treatment groups (scale 0–48, with a higher score indicating a better outcome) over the 2-year period [difference of 0.75 points in favour of the surgery group, 95% confidence interval (CI) –1.33 to 2.84;p = 0.479; data from 114 surgery and 117 non-surgery participants] or at individual time points. We found no statistically significant differences between surgical and non-surgical group participants in SF-12 physical or mental component summary scores; surgical or shoulder fracture-related complications (30 vs. 23 respectively); those undergoing further shoulder-related therapy, either surgery (11 vs. 11 respectively) or other therapy (seven vs. four respectively); or mortality (nine vs. five respectively). The base-case economic analysis showed that, at 2 years, the cost of surgical intervention was, on average, £1780.73 more per patient (95% CI £1152.71 to £2408.75) than the cost of non-surgical intervention. It was also slightly less beneficial in terms of utilities, although this difference was not statistically significant. The net monetary benefit associated with surgery is negative. There was only a 5% probability of surgery achieving the criterion of costing < £20,000 to gain a quality-adjusted life-year, which was confirmed by extensive sensitivity analyses.ConclusionsCurrent surgical practice does not result in a better outcome for most patients with displaced fractures of the proximal humerus involving the surgical neck and is not cost-effective in the UK setting. Two areas for future work are the setting up of a national database of these fractures, including the collection of patient-reported outcomes, and research on the best ways of informing patients with these and other upper limb fractures about initial self-care.Trial registrationCurrent Controlled Trials ISRCTN50850043.FundingThis project was funded by the NIHR Health Technology Assessment programme and will be published in full inHealth Technology Assessment; Vol. 19, No. 24. See the NIHR Journals Library website for further project information.

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